Notices, Disclosures and Agreements

Below are the rules and regulations for Parker Therapy Group.

Attenance Agreeement

We at Parker Speech and Language understand that on occasion cancellations will occur. We ask that in the event these cancellations occur, you discuss a make -up date with your therapist. Our office policy requires an 80% attendance rate in order to maintain your weekly assigned appointments. If your attendance rate falls below 80% within a 60-day period, the patient is at risk for being discharged. You may be asked by your therapist to change your weekly appointment in order to maintain the 80% attendance rate.

Cancellation Disclaimer

In the event of cancellation without 24-hour notice, you will be charged a $25.00 fee. This fee is not payable by insurance. We recognize emergencies do occur and we will attempt to make accommodations for special circumstances. After three “No Shows” (defined as not appearing for a scheduled appointment with less than 24-hour notice of cancellation) the patient will be discharged. By initialing below, you acknowledge sole responsibility for payment of any fees incurred under the foregoing policy.

Home Pratice

Weekly assignments will be given for you to perform at home or out in the community. You agree to perform these exercises/assignments with your child (or self) at least 2-3 times per week as demonstrated by your therapist. You acknowledge these assignments will help ensure mastery of skills taught in therapy. You understand that not performing these assignments could be a detriment to your therapeutic progress

Insurance Disclosure

Parker Speech and Language does not guarantee payment from your insurance for speech therapy services. As a courtesy to you, we will submit all claims to your health insurance carrier to collect payment. Copays, coinsurance or other applicable payment is due at the time of service. It is not our responsibility to maintain a balance for services rendered to the patient while insurance claims are pending. If insurance takes more than 60 days to pay the provider for services rendered, you will be personally responsible for paying Parker Speech and Language Therapy for incurred therapy charges. If payment cannot be made in full after 30 days, a payment agreement may be arranged. Therapy will be placed on hold until payment is received in full. It is the patient’s responsibility to notify Parker Speech and Language Therapy of any type of insurance change. We are not responsible for lack of coverage if your insurance changes. By initialing below, you acknowledge sole responsibility for any fees that are not paid by your insurance provider. In the event your insurance excludes speech therapy services, you agree to enter into contract with Parker Speech and Language Therapy for a cashrate fee, which will be paid at the time services are provided.

Assignment of Benefits

In the event you, or the patient you are responsible for, are entitled to benefits of any type from a medical insurance provider or otherwise for services rendered by Parker Speech and Language Therapy, you hereby irrevocably assign such benefits to Parker Speech and Language Therapy for application to your bills for services rendered. You request that payments of claims be made on your behalf to Parker Speech and Language Therapy

Financial Agreement

You acknowledge that you are fully responsible for all speech therapy fees. Parker Speech and Language Therapy will submit claims to your insurance company on your behalf and you will be responsible for paying copays or session charges each session. You will not hold Parker Speech and Language Therapy responsible for any incurred charges. Payment is due at the time services are rendered and no balances, including copays, shall be carried past 30 days without penalty of services being discontinued or placed on hold. In the event of default of payment or if your account is placed with an attorney or collection agency for collection of balance, you agree to pay attorney’s fees and court costs associated with any collection efforts, if applicable. You authorize Parker Speech and Language Therapy to provide physician- prescribed treatment for the patient and understand that no guarantee or assurance has been made regarding potential outcomes or results that may be obtained regardless of the cost incurred for treatment. Accounts past due by 60 days will be charged $25.00 after 60 days and $25.00 for every month thereafter until the balance is paid in full. I understand all NSF checks will be subject to a $25.00 fee

Media Marketing Release

This is a Paragraph. Click on "Edit Text" or double click on the text box to start editing the content and make sure to add any relevant details or information that you want to share with your visitors.

Acknowledgedement of Receipt of Privacy Practices and Office Policies

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

Uses and Disclosures We will use your protected health information (PHI) for the purposes of treatment, payment and health care operations.

Treatment includes the disclosures of health information to other providers who have referred you for services or are involved in your care. This may include doctors, nurses, technicians and other therapists. For example, we may feel that a stroke patient we are treating would benefit from an evaluation by a physical therapist to address a difficulty. The health information we share with the physical therapist would be considered a treatment related disclosure.

Payment includes the disclosure of health information to your insurance company, including Medicare and Medicaid, so payment can be obtained for services rendered. Your insurance company may make a request to review your medical record to determine that your care was necessary.

Health Care Operations include the utilization of your records to monitor the quality of care being given at our facility or for business planning activities.

Other Special Uses

Our practices may use your PHI to send you an appointment reminder, to inform you of our other health related products and services or to request a contribution to our charitable activities.

Uses and Disclosures Required by Law

The federal health information privacy regulations either permit or require us to use or disclose your PHI in the following ways: we may share some of your PHI with a family member or friend involved in your care if you do not object, we may use your PHI in an emergency situation when you may not be able to express yourself, and we may use or disclose you PHI for research purposes if we are provided with very specific assurances that your privacy will be protected. We may also disclose your PHI when we are required to do so by law, for example by court order or subpoena. Disclosures to health oversight agencies are sometimes required by law to report certain diseases or adverse drug reactions. We may use and disclose health information about you to avert a serious threat to your health or safety or the health or safety of the public or others. If you are in the Armed Forces, we may release health information about you when it is determined to be necessary by the appropriate military command authorities. We may also release information about you for workers’ compensation or other similar programs that provide benefits for work–related injury or illness. Your authorization is required before your PHI may be used or disclosed by us for other purposes.

Your Privacy Rights

Restrictions

You have the right to request restrictions on how your PHI is used: however, we are not required to agree with your request. If we do agree, we must abide by your request.

Confidential Communications

You have the right to request confidential communication from us at a location of your choosing. This request must be in writing. Access to PHI You have the right to request a copy of your medical record. You must make this request in writing and we may charge a fee to cover the costs of copying and mailing. Amendments You have the right to request an amendment be made to your PHI, if you disagree with what it says about you. This request must be made in writing. If we disagree with you, we are not required to make the change. You do have the right to submit a written statement about why you disagree that will become part of your record. We may not amend parts of your medical record that we did not create.

Accounting of Disclosures

After April 14, 2003, you have the right to request an accounting of the disclosures made in the previous six years. These disclosures will not include those made for treatment, payment or health care operations of for which we have obtained authorization.

Complaints

If you feel that your privacy rights have been violated, you have the right to make a complaint to us in writing without fear of retaliation. Your complaint should contain enough specific information so that we may adequately investigate and respond to your concerns. If you are not satisfied with our response, you may complain directly to the Secretary of Health and Human Services.

Our Duty to Protect Your Privacy

We are required to comply with the federal health information privacy regulations by maintaining the privacy of your PHI. These rules require us to provide you with this document, our Notice of Privacy Practices. We reserve the right to update this notice if required by law. If we do update this notice at any time in the future, you will receive a revised notice when you next seek treatment from us.

Privacy Contact If you would like more information about our privacy practices or to file a complaint you may contact:

Kay H. Parker

19105 Sandy Lane Ste A

Covington, LA 70433

985-705-5330

Effective Date: This notice will take effect on June 1, 2018